Melanoma 10/6/16

Collecting
NAACCR Cancer Data:
2015-2016
Melanoma
Webinar
Series
NAACCR 2016-2017 Webinar Series
Presented by:
Angela Martin amartin@naaccr.org
Jim Hofferkamp jhofferkamp@naaccr.org

Q&A

• Please submit all questions concerning webinar content through the

Q&A panel.
• Reminder:
– If you have participants watching this webinar at your site, please collect their
names and emails.
– We will be distributing a Q&A document in about one week. This document
will fully answer questions asked during the webinar and will contain any
corrections that we may discover after the webinar.

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Fabulous Prizes

Agenda

• Overview
• Epi Moment
• Treatment
• Quiz 1
• Staging
• Quiz 2
• Case Scenarios

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Melanoma
Overview

Layer of Skin

• Epidermis
• Dermis
• Subcutaneous

Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.

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Skin Cells
• Squamous
– Flat cells
– Outer part of epidermis
• Basal
– Divide to replace squamous cells that shed
– Lower part of epidermis
• Melanocytes
– Melanin
– Protects deeper layers of skin
– Exposed to sun make more pigment

Melanoma Skin Cancers

• Less common than basal and squamous cell cancer

• More dangerous because can spread

• Men: Trunk; Women: Legs

• Less common areas: eyes, mouth, genitals and anal area

• Palms of hands, soles of feet, under nails: African Americans, Asians,

Hispanics

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Types of Melanoma

• Superficial Spreading Melanoma (8743)

• Nodular Melanoma (8721)
• Lentigo Maligna Melanoma (8742)
• Acral Lentiginous Melanoma (8744)
• Malignant melanoma, NOS (8720)

Possible Signs of Melanoma - ABCDE

• Asymmetry

• Border

• Color

• Diameter

• Evolving

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Possible Signs of Melanoma – Other Signs

• Sore doesn’t heal

• Spread of pigment

• Redness or new swelling beyond border of the mole

• Change in sensation, itchiness, tenderness or pain

• Change in surface of mole

Laterality

• Draw a line from mid forehead to mid pelvis and from mid
skull to mid buttocks – divides body into right and left half
– Right
– Left
– midline

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Multiple Primary and Histology Rules

• M3 – Topography codes different at second (Cxx.x), third

(Cxx.x) or Fourth character (Cxx.x) are multiple primaries
• Example
– Patient has invasive melanoma on right leg (C44.7) and
an invasive melanoma on right arm (C44.6)

Multiple Primary and Histology Rules

• M4 – Different laterality are multiple primaries

• Example
– Patient has invasive melanoma on right leg (C44.7) and
an invasive melanoma on midline trunk (C44.5)

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Multiple Primary and Histology Rules

• M5 – Histology codes different at first (xxxx), second

(xxxx) or third number(xxxx) are multiple primaries
• Example
– Patient has invasive melanoma (8720/3)on right leg
(C44.7) and another invasive superficial spreading
melanoma (8743/3) on right leg (C44.7)

Multiple Primary and Histology Rules

• M6 – Invasive melanoma more than 60 days after an

insitu melanoma is a multiple primary

• M7 – melanomas more than 60 days apart multiple

primaries

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Multiple Primary and Histology Rules

• H5 – Code histologic type when diagnosis is regressing

melanoma and a histologic type

• H6 – Code 8723 (malignant melanoma, regressing) when

diagnosis is regressing melanoma

Multiple Primary and Histology Rules

• H7 – Code histologic type when diagnosis is lentigo

maligna melanoma and a histologic type

• H8 – Code 8742 (lentigo maligna melanoma) when the

diagnosis is lentigo maligna melanoma

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Multiple Primary and Histology Rules

• H9 – Code most specific histology term: melanoma, NOS

with a single specific type
• In situ lesions
» Pattern, architecture, type, subtype, predominantly, with
features of , major or with ___ differentiation
• Invasive lesions
» Type, subtype, predominantly, with features of , major or
with ___ differentiation

Epi Moment
Melanoma
Theme song: Theme from Endless
Summer

20

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Epidemiology of Malignant Melanoma

• Increasing worldwide
– 3-7% annually for whites
– Highest in Australia/New Zealand
• 2x NA (climate, demographics, & location/ozone)
– Influenced by geography (UV exposure)
– Better detection or more sun exposure?
• Sun seeking habits & depleting ozone
• Higher among men than women
– 25.7 versus 16.0 incidence
– 4.1 versus 1.7 mortality
• Higher among whites
– 22.9 versus 4.8 AI/ANs; 1.3 APIs, 1.0 blacks incidence
– 3.1 versus <1 mortality
• Higher among non-Hispanics
– 25.6 versus 4.5 incidence
– 2.9 versus <1 mortality

Malignant Melanoma Trends, 1995-2013

Increasing, 2.2% annually

Stable, 2.7 per 100,000

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Cutaneous Melanoma
• Superficial spreading melanoma
– 70% of all cases, common in young people
– Common on upper back & trunk in men, legs in women
– Flat or slightly raised discolored path with irregular borders; often in moles, Spreads
superficially
• Nodular melanoma
– 10-15% of all cases, common in elderly
– Generally invasive at dx, aggressive
– Black or other discoloration, bump on trunk, legs & arms
• Lentigo maligna
– 10% of all cases, In situ, common in elderly (Hawai’i)
– Flat or slightly elevated tan or brown discoloration, Spreads superficially & slow
– Sun-exposed, damaged skin on face, ears, arms & upper trunk
– Malignant, lentigo meligna melanoma

Cutaneous Melanoma
• Acral lentiginous melanoma
– <5% of all cases, common in blacks, Asians (not whites)
– Spreads superficially,
– Black or brown discoloration under the nails (subungal) or on the soles of the feet or
palms of the hands
• Amelonitic melanoma
– <5% of all cases, “without melanin”, can be difficult to diagnosis due to lack of color

• Treatment similar, stage based

– Surgery, sometimes radiation and/or infereron
– Chemos and experimental therapies for advanced stage

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Extracutaneous Melanoma
• Mucosal melanoma <2% of all cases
– Aggressive, poor prognosis
– Generally advanced stage at dx (location not easily seen)
– Located in mucosal membranes lining respiratory, gastrointestinal and urogenital tract
– Surgery main tx; movement away from radical surgery, Radiation does not improve survival
• Ocular melanoma
– Most common extracutaneous type
– Uveal (choroidal—most common, iris, ciliary body) & and conjunctival types
– Surgery or Radiation or both
• Leptomeningeal
– Poor prognosis—median survival 6-8 weeks
– Not usually a primary cancer, a metastatic
• Internal organs
– Rare, also often metastatic

Risk Factors for Melanoma

• Age, Moles (nevus)
• Fair skin, freckles, light hair
• Family history
– Shared exposures; skin tone
– No genetic testing currently recommended
– Xeroderma pigmentosum (rare, inherited, can’t repair DNA damage to skin cells)
• Previous melanoma, Weakened immune system
• UV exposure (sunlight, tanning beds)
– UV small % of suns rays but damages DNA, causes cancer when DNA of genes controlling skin cell
growth are damaged
– Frequent sunburns, esp childhood (intermittent not occupational)
– Risk for cutaneous and ocular; not a risk for other types
– 2009: more tanning salons than coffee shops
• Newer devices modified to decrease sun burn; still classed as carcinogen
• Occupational exposures

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Melanoma Survival

• 90%, 5 year relative
• Survival rates ↑
• Lower
– Blacks
– Late stage
– Older age

Issues with melanoma screening

• Lifetime risk of melanoma 1 in 63 (invasive)
– Median age at dx 52; 25% < 45
• Incidence increasing
– Better detection or more sun exposure?
• Survival rates increasing but mortality no change
– No true progress against disease
• Self-examination, clinical skin exams
– Common at community health fairs
– Regular exams (self & clinical) promoted by ACS and other advocacy groups
• 7/22/16 USPSTF
– Insufficient evidence to assess benefits versus harms of visual skin exams to screen for melanoma
– Visual skin examination modest sensitivity and specificity for detecting melanoma
• Harms: misdiagnosis, over-diagnosis
– More limited than other cancers (i.e. removal of mole) but can lead to adverse effects, both cosmetic &
occasionally functional

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Issues with melanoma reporting

• Underreported
– Due to decentralization of diagnosis
– Outside hospital system
– Particularly early stage
– In situ and local
• BUT rates ↑, over‐diagnosis!
– Increasing screening
• % early stable since 1995, likely a factor prior
– Increasing risk
– Increasing ascertainment
• % path & % phys repor ng ↑ since 1995
• 6 → 11% path; 8 → 19% phys
• Rates very highly correlated with % path & 
phys
• Reporting inconsistent by geography
• Caution when comparing rates over time or between 
geographies
– Large differences unlikely to represent large 
changes in risk

Melanoma Research
• Focus on sun protection, indoor tanning
– Healthy behaviors; impact of health campaigns
– Impact of regulation
– Targeting minorities (Hispanics)
• Additional risk factors
– SES, diet
• CiNA
Solar ultraviolet-B exposure and cancer incidence and mortality in the United States, 1993-2002
Boscoe FP, Schymura MJ., BMC Cancer, 2006
The relationship between area poverty rate and site-specific cancer incidence in the United States
Boscoe FP, Johnson CJ, Sherman RL, Stinchcomb DG, Lin G, Henry KA. Cancer, 2014
• Melanoma Monograph
– J Am Acad Dermatolo 2011
• Rad Tech
– NOT RISK FACTORS: height, weight, BMI, age at menarche, menopausal status, HRT, parity, or
contraceptive use
– BUT BRCA2 is a risk
– Modest increase of risk prior to 1950 or if not using lead aprons/shields

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Melanoma Treatment

Standard Scenario
• Patient or physician identifies a suspicious lesion and excises the tumor.
– Tries to get close margins.
– Thorough physical exam is performed.
• Tumor comes back as melanoma.
– If necessary, imaging is performed.
• Definitive surgery is performed. Usually, some form of wide excision
– If warranted, sentinel lymph node biopsy is performed.
– If warranted, lymph node dissection
• Based on stage, patient may have adjuvant treatment.
• Follow-up plan.

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Diagnostic Staging Procedure

• Tumor is very large

• Tumor in a site that is difficult to biopsy
• Margins will be grossly positive on pathology
• Code as a diagnostic staging procedure code 02.

Biopsies

• Excisional
• Punch
• Shave

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Wide Excision

• Follows the excisional biopsy

• Removes a margin of healthy tissue from around the
melanoma site.
• If the margin of healthy tissue is 1cm or less, or the margin
of healthy tissue is not stated
• code this procedure using codes 30-33.

Surgery Codes

• Code 30 – original excisional biopsy or technique was not

indicated
• Code 31 – original excisional biopsy was a shave biopsy
• Code 32 – original excisional biopsy was a punch biopsy
• Code 33 – original incisional biopsy and then wide excision
was done*

*incisional biopsy coded as diagnostic staging procedure

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Surgery Codes

• Code 45 – wide excision with margins more than 1 cm but not

documented if more or less than 2 cms

• Code 46 – wide excision with margins more than 1 cm or equal

to or less than 2 cms

• Code 47 – wide excision and margins are more than 2 cms

Melanoma

Quiz 1

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Melanoma
Summary Stage
TNM Staging

39

Standard Scenario
• Patient or physician identifies a suspicious lesion and excises the tumor.
– Tries to get close margins.
– Thorough physical exam is performed.
• Tumor comes back as melanoma.
– If necessary, imaging is performed.
• Definitive surgery is performed. Usually, some form of wide excision
– If warranted, sentinel lymph node biopsy is performed.
– If warranted, lymph node dissection
• Based on stage, patient may have adjuvant treatment.
• Follow-up plan.

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Melanoma
Summary Stage
TNM Staging

41

Summary Stage

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Summary Stage
• 0 In situ:
– Noninvasive; intraepithelial
– Basement membrane of the epidermis is
intact; intraepidermal
– Clark’s level I
• 1 Localized only
– Papillary dermis invaded-Clark’s level II
– Papillary-reticular dermal interface invaded-
Clark’s level III
– Reticular dermis invaded-Clark’s level IV
– Skin/dermis, NOS
– Localized, NOS

Summary Stage
• 2 Regional by direct extension only
– Subcutaneous tissue invaded (through entire 
dermis)
– Clark’s level V
– Satellite nodule(s), NOS
– Satellite nodule(s) < 2 cm from primary tumor
• 3 Regional lymph node(s) involved only
– REGIONAL Lymph Nodes by primary site
– All sites:
• In‐transit metastasis (satellite nodules >2 cm from 
primary tumor)
• Regional lymph node(s), NOS

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Summary Stage

• 4 Regional by BOTH direct extension AND regional lymph 
node(s) involved
• 5 Regional, NOS
• 7 Distant site(s)/lymph node(s) involved
• 9 Unknown if extension or metastasis

Summary Stage: Notes

• Note 1: For melanoma of sites other than those above, use site‐
specific schemes.
• Note 2: If there is a discrepancy between the Clark’s level and the 
pathologic description of extent, use the higher Summary Stage 
code.
• Note 3: Skin ulceration does not alter the classification. Skin 
ulceration was considered regional in Historic Stage.
• Note 4: In‐transit metastasis was considered regional by direct 
extension in Historic Stage and Summary Stage 1977

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TNM Stage
Page 325

Rules for Classification

• Clinical
– Complete excision of the primary tumor
– Clinical assessment (physical exam and imaging only) of the regional
lymph nodes and intralymphatic metastasis.
• Pathologic
– Wide-excision/re-excision is considered definitive treatment
– Pathologic assessment of regional nodes after sentinel lymph node biopsy
and/or complete regional lymphadenopathy.
– Pathologic confirmation of intralymphatic (satellite or in-transit
metastasis).
• Would be highly unusual to have pathologically confirmed intralymphatic metastasis
and no lymph nodes removed.

48

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Primary Tumor

• “T” value is based on ….
– Breslow’s depth
– Ulceration (cannot assume no ulceration if not mention of 
ulceration)
– Mitotic rate (sometimes)
• Excision of the primary tumor is part of the clinical evaluation.
• Wide excision or re‐excision are a definitive surgeries that meet 
the criteria for pathologic stage
(see page 335)

Pop Quiz
Data Item Value
• A patient present for annual screening  Clinical T cT2a
by a dermatologist and is found to 
have a 6mm suspicious lesion on her  Clinical N cN0
calf. The lesion is removed. No  Clinical M cM0
additional abnormalities were seen 
Clinical Stage 1B
during the physical exam.
• Pathology revealed a malignant  Pathologic T
melanoma. Pathologic N
– Breslow’s depth: 1.3 mm.  Pathologic M
– No ulceration was identified. 99
Pathologic Stage
• The patient did not return for any 
additional work‐up or treatment.

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Pop Quiz
Data Item Value
• A patient presented for an annual  cT2a
Clinical T
screening and was found to have a 6mm 
suspicious lesion on her calf. The lesion  Clinical N cN0
was removed. No additional abnormalities 
were seen during the physical exam. Clinical M cM0
• Pathology revealed a malignant  Clinical Stage 1B
melanoma. Pathologic T pT2a
– Breslow’s depth: 1.3 mm. 
Pathologic N
– No ulceration was identified. pNX
• The patient returned for a wide excision  Pathologic M cM0
that was negative for residual carcinoma.  Pathologic Stage 99
No additional surgery was performed.

Pop Quiz
• A patient has a suspicious mole removed at her Data Item Value
physician's office. Clinical T cT2
• Pathology confirmed a melanoma with Breslow’s
depth of 1.2mm. Clinical N cN0
• Physical exam did not show enlarged lymph nodes. Clinical M cM0
• A sentinel lymph node biopsy showed micro
metastasis in 1 of 3 lymph nodes. Clinical Stage 99
• A wide excision did not reveal an residual disease. Pathologic T pT2
• She then had a lymphadenectomy with removal of
Pathologic N
12 lymph nodes that were all negative for pN0
malignancy. Pathologic M cM0
• No further treatment was done.
Pathologic Stage 99

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Pop Quiz
Data Item Case 1 Case 2 Case 3
• Same scenario, path report Clinical T cT2 cT2a cT2b
documented no ulceration.
Clinical N cN0 cN0 cN0
– What is the cT and pT?
Clinical M
– What are the cStage and cM0 cM0 cM0
pStage? Clinical Stage 99 1B 2A
• Same scenario, path report Pathologic T pT2 pT2a pT2b
documented ulceration was Pathologic N pN0 pN0 pN0
present. Pathologic M cM0 cM0 cM0
– What is the cT and pT? Pathologic  99 1B 2A
– What are the cStage and Stage
pStage?

cN Regional Lymph Nodes

• Based on imaging and physical done prior to definitive surgery (wide 
excision). 
– cNX ‐ Cannot be assessed
– cN0 ‐ No evidence of regional node metastasis
– cN1‐ 1 or more clinically apparent metastasis
– cN2‐ 2‐3 clinically apparent lymph nodes
– cN2c ‐ In‐transit or satellite metastasis (no positive lymph nodes)
– cN3 
• 1 or more clinically apparent nodes and in‐transit or satellite metastasis or
• More than 3 positive lymph nodes 

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Intralymphatic Metastasis

• Satellites (microsatellite)
– Nodules occurring in the 
lymphatic channels within 2cm 
of the primary lesion
• In‐transit metastasis
– Metastasis in the lymph 
lymphatic channel occurring 
between the primary and the 
lymphatic basin

Intralymphatic Metastasis

• cN2c
– Satellite or In‐transit mets 
identified prior to definitive 
surgery.
• pN2c
– Pathologically confirmed. 

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pN Regional Lymph Nodes

• Surgically removed regional lymph nodes
– pN1 – 1 node with positive lymph nodes
• pN1a micrometastasis
• pN1b macrometastasis A and B categories only 
– pN2 – 2‐3 positive lymph nodes For pN
• pN2a micrometastasis
• pN2b macrometastasis
• pN2c in‐transit/satellite metastasis without lymph node metastasis
– pN3 – 4 or more metastatic nodes or matted nodes or in‐transit 
metastasis/satellite metastasis with metastatic nodes

Micrometastasis vs Macrometastasis
• Comparing cN with pN
• Micrometastasis
– cN0
• Not enough tumor in a lymph node to be felt during physical exam or seen 
on imaging.
– Lymph nodes positive for malignancy on surgical exam.
– Clinically occult
• Macrometastasis
– Clinically apparent lymph node metastasis
• Enough tumor is present in the lymph nodes to make them palpable or to 
appear malignant on imaging

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Sentinel Node Biopsy

• Usually done on cN0 patients with 
cT1b or higher.
• Radioactive die is injected around 
the site of the melanoma
• Die is traced to nodes that the 
tumor drains to.
• May be multiple nodes in multiple 
basins

Metastasis from an Unknown Primary

• If a patient presents with a 
positive lymph node and an 
adequate work‐up fails to 
reveal a primary tumor, code 
the lymph node as regional.

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Pop Quiz
Data Item Value
• A patient present with an enlarged  Clinical T cT0
cervical lymph node.  Clinical N cN1
• An excisional biopsy is done and  Clinical M cM0
confirms metastatic melanoma.  Clinical Stage 3
• A thorough physical exam is  Pathologic T
conducted and  no primary tumor  Pathologic N
is identified. Imaging does not 
Pathologic M
show any additional abnormalities.
Pathologic Stage 99

Page 335 and 336

Pop Quiz
• A patient presents for annual screening and is  Data Item Value
found to have a suspicious mole. The mole is  Clinical T cT1b
excised and found to be malignant melanoma 
(cT1b). No palpable lymph nodes were present.  Clinical N cN0
• The patient returned two weeks later for a  Clinical M cM0
sentinel lymph node biopsy and wide excision. Clinical Stage 3
• Pathology 
Pathologic T
– Wide exicison: Negative for residual  pT1b
melanoma Pathologic N pN0
– Sentinel node biopsy:  Pathologic M cM0
• 4 lymph nodes removed. Micrometastasis 
measuring less than 0.1mm in a single lymph  Pathologic Stage 99
node.  3 lymph nodes negative for metastasis.
Page 335 and 336

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pStage III

• Stage group IIIA

– pT1a, pT2a, pT3a, or pT4a
– pN1a or pN2a
– cM0

– pT1b, pT2b, pT3b, pT4b

– pN1a or pN2a
– cM0
Page 336 63

Distant Metastasis

• M1a
– Metastasis to the skin, subcutaneous tissue, or distant lymph 
nodes
• M1b
– Metastasis to the lung
• M1c
– Metastasis to any other “visceral” sites
– Distant metastases to any site combined with an elevated LDH

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Serum lactate dehydrogenase (LDH)

• Blood test
• Elevated LDH can help predict survival for patients with distant 
metastasis.
• Can be a good indicator of recurrent disease.
• LDH is not an effective test to diagnose melanoma
• LDH is not an effective test to identify regional or distant 
metastasis

65

Pop Quiz
• A patient was found to have cT3b Data Item Value
melanoma. cT3b
Clinical T
• Imaging and physical exam did not show
any suspicious lymph nodes, but did show a Clinical N cN0
malignant appearing mass in the left lung. Clinical M pM1c
• A bronchoscopy with biopsy was positive for
malignant metastatic melanoma. Clinical Stage 4
• The LDH was elevated. Pathologic T pT3b
• The patient then had a sentinel node biopsy Pathologic N pN2a
and wide excision.
Pathologic M pM1c
– Sentinel node biopsy showed two positive
lymph nodes. Pathologic Stage 4
– Wide excision was negative for residual
metastasis.

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Pop Quiz
Data Item Value
• A patient presents with a solitary Clinical T cT0

brain metastasis. Clinical N cN0

• A biopsy confirmed malignant Clinical M pM1c

melanoma. Clinical Stage 4
Pathologic T
• Work-up revealed no primary site Pathologic N
no other disease Pathologic M pM1c
• The LDH was normal. Pathologic Stage 4

Questions?

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SSF1

• Measured Thickness (Depth), Breslow Measurement

– Documents depth of invasion of primary melanoma
– Predicts risk of nodal metastasis
– Is a factor in determining T category
– Record to hundredths of mm as documented in path report
– Record greatest measurement from any procedure whether
biopsy or excision

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SSF2

• Ulceration
– Is the absence of intact epidermis over the melanoma
– Is an important adverse prognostic factor
– Record presence or absence of ulceration as
documented in path report
• Code as 000 (no ulceration present) if there is no documentation
or mention of ulceration in path report
• Caution…this is not the same rule we use to assign the a and b
subcategories for the T value!

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SSF3

• Clinical Status of Lymph Node Mets

– Tumor burden in regional nodes is an important
prognostic factor
• Micrometastases
– Clinically inapparent metastasis histologically diagnosed after sentinel
node biopsy and lymphadenectomy (if performed)
• Macrometastases
– Clinically detected nodal metastasis confirmed by lymphadenectomy or
nodal metastasis with gross extracapsular extension

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SSF4

• Serum Lactate Dehydrogenase (LDH)

– Is a significant predictor of survival among patients who
present with or develop distant metastasis
– Record range for positive LDH prior to treatment or within 6
weeks of diagnosis
• First positive test is priority
– Is a factor in determining M category
– Use same test to code SSF4, SSF5, and SSF6

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SSF4
• Positive LDH results from 2 lab tests required to code as positive
– Assign code 000 (within normal limits) if 1st test positive and 2nd test
negative
– Assign code 998 (test not done) if 1st test positive and no 2nd test
performed
– Assign code 999 (unknown) if 1st test positive and no information
about 2nd test
– Assign code 000 if only 1 test performed and it is within normal limits

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SSF7

• Primary Tumor Mitotic Count/Rate

– Increasing mitotic rate correlates with decline in survival
– Based on number of mitoses in one square mm
surrounding a ‘hot spot’ or a field with representative
mitosis
– Is a factor in determining T category
– Record mitotic rate/count as documented in path report

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Questions?

Coming Up…

• Collecting Cancer Data: Melanoma
– 10/6/2016

• Collecting Cancer Data: Hematopoietic and Lymphoid Neoplasm
– 11/3/2016

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Fabulous Prizes

CE Certificate Quiz/Survey

• Phrase

• Link
– http://www.surveygizmo.com/s3/3081649/Melanoma‐2016

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Thank You!

Jim Hofferkamp jhofferkamp@naaccr.org
Angela Martin amartin@naaccr.org
Recinda Sherman rsherman@naaccr.org

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